Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 143297 | UT |
NPI | 1003079260 |
---|---|
Provider Name | Ivan K Hendrickson |
First Address | St George, UT 84790-5584 |
Second Address | St George, UT 84790-5584 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2008 |
Last Update Date | 06/03/2013 |